AUTHORIZATION AND IRREVOCABLE INSTRUCTIONS TO HEALTHCARE PRACTITIONER FOR MEDICARE, MEDICAID AND ALL OTHER INSURANCE PLANS
"I hereby authorize and irrevocably instruct any physician, health care practitioner, hospital, clinic, or other medical or medically related facility to furnish any and all records, medical history, services rendered or treatment given to me or any dependent for purposes of review, investigation or evaluation of any claim submitted to Health Insurance Plans.
I also authorize Medicare, Medicaid or/and other Health Insurer to disclose to a hospital or health care service plan, self-insurer, or an insurer any medical information obtained if such disclosure is necessary to allow the processing of any claim.
If my coverage is under a Group Contract held by an employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or audit. This authorization shall become effective immediately upon execution and snail remain in effect for the duration of any claim or term of coverage with BLUE SHIELD or other insurer including a reasonable time thereafter, until its final consummation.
This authorization shall be binding upon me, my dependents, and our heirs, executors and administrators."
MEDICARE AND MEDICAID
"I request that payment of authorized Medicare benefits be made my behalf to this office for any services furnished by that physician to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services."
AUTHORIZATION AND IRREVOCABLE INSTRUCTION TO PAY FOR SERVICES RENDERED:
"I request payment of this claim and, if the payer accepts assignment, authorize payment direct to the physician group, physician, health care practitioner, hospital, clinic, or supplier for the services described."
I Authorize Amerihealth Group on behalf of physician group, physician, health care practitioner, hospital, clinic, or supplier to bill my health insurance account for the health services provided to me. In the event that the Company is unable to obtain from my insurance provider payments for the services, I authorize the Company to charge my credit or debit card for agreed upon purchases of the services.
I understand that my information will be saved to a file for future transactions on my account. I understand that the Company reserves any and all rights applicable under the law to collect my outstanding debt, including but not limited to employing services of third-party
collectors.
I give consent to the Company to contact me via e-mail, phone, or text messages for administrative, Healthcare, billing, and other purposes in connection to the services provided by the Company. It is my understanding I may be contacted via an automated dialer or messaging system and pre-recorded messages will be left from the automated system if I am unable to accept the call.